Cytogenetic and clinical investigations in 76 cases with therapy-related leukemia and myelodysplastic syndrome

Cytogenetic and Clinical Investigations in 76 Cases with Therapy-related Leukemia and Myelodysplastic Syndrome Alessandra Iurlo, Cristina Mecucci, Angeline Van Orshoven, Jean-Louis Michaux, Marc Boogaerts, Lucien Noens, Andr~ Bosly, Andries Louwagie, and Herman Van Den Berghe

ABSTRACT: Clinical, cytomorphologic, and cytogenetic investigations were carried out in a series of 76

secondary MDS and ANLL. Chromosome abnormalities were more frequent in patients with a history of multiple myeloma or macroglobulinemia (92%) and myeloproliferative disorders (82%) than in patients with previous breast cancer 140%). The secondary hematologic malignancies were mostly a trilineage bone marrow disorder. The most commonly found cytogenetic anomaly was monosomy 7, followed by total or partial loss of chromosome 5. In addition six other chromosomes, i.e., chromosome 3, 8, 9, 12, 17, and 21 seemed to be consistently inw~lved in the pathogenetic mechanisms of secondary leukemia and MI)S.

INTRODUCTION T h e d e v e l o p m e n t of a m y e l o d y s p l a s t i c s y n d r o m e (MDS) a n d / o r a c u t e l e u k e m i a (ANLL) after c h e m o t h e r a p y a n d / o r r a d i o t h e r a p y for n e o p l a s t i c a n d n o n n e o p l a s t i c d i s o r d e r s r e p r e s e n t s t h e m o s t i m p o r t a n t c o m p l i c a t i o n for p a t i e n t s s u c c e s s f u l l y treated. S e c o n d a r y A N L L is u s u a l l y d i s t i n g u i s h a b l e f r o m d e n o v o A N L L o n b o t h m o r p h o logic a n d c l i n i c a l g r o u n d s i n t h a t s-ANLL is o f t e n p r e c e d e d b y a n MDS. A c o m p l e t e r e m i s s i o n is r a r e l y o b t a i n e d w i t h c o n v e n t i o n a l c h e m o t h e r a p y . C h r o m o s o m e a n o m a lies t y p i c a l l y i n v o l v i n g c h r o m o s o m e s 5 a n d / o r 7 are p r e s e n t i n m o r e t h a n 8 0 % of cases [1-3]. T h e a i m of t h i s s t u d y w a s to i n v e s t i g a t e c h r o m o s o m e a n o m a l i e s in 68 p a t i e n t s i n w h o m M D S or A N L L d e v e l o p e d after c h e m o - a n d r a d i o t h e r a p y for h e m a t o l o g i c or

From the Center for Human Genetics (A. I., C. M., H. V. D. B.), Central Clinical Laboratory (A. V. O.], and Department of Haematology (M. B.J, University of Leuven, Belgium, the Department of Hematology, Universite de Louvain, Belgium (J-L. M.), the Department of Hematology, University of Gent, Belgimn (L. N.), the Department of Internal Medicine, Universit0 de Louvain h Mont-Godinne, Yvoir, Belgium (A. B.), and the Department of Hematology, Brugge, Belgium (A. L.). Present addresses are: A. I.. Istituto di Scienze Mediche, University of Milano, Italy; C. M.. Clinica Medica 1, University of Perugia, Italy. Address reprint requests to: Dr. /3. Van Den Berghe, Center for Human Genetics, Herestraat 49, B-3000 Leuven, Belgium. Received February 16, 1989; accepted May 30, 1989.

227 © 1989 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010

Cancer Genet Cytogenet 43:227 241 (19891 0165~4608/89/$03.50

228

A. Iurlo et al.

solid tumors. Eight additional cases of possibly i n d u c e d ANLL or MDS i n c l u d e d four patients treated with c y c l o p h o s p h a m i d e for multiple sclerosis or a u t o i m m u n e thyroiditis, three workers previously exposed to chemical toxic agents, and one patient who received thorotrast for diagnostic purposes. Analysis of the cytogenetic data from this large series of secondary MDS and ANLL c o m p a r e d to data from the literature proved useful for a better delineation of the most consistently occurring c h r o m o s o m e aberrations in these hematologic malignancies. Information on survival was also obtained.

MATERIALS AND METHODS

Seventy-six patients w h o d e v e l o p e d s-ANLL and/or s-MDS were studied between 1973 and May 1987 at the University of Leuven. Seventy-two patients had a history of treatment with c h e m o t h e r a p y a n d / o r radiotherapy, while four had a d o c u m e n t e d exposure to other toxic agents. Clinical data collected were sex, age, primary disease, treatment, interval time before the a p p e a r a n c e of secondary neoplasia, treatment for second malignancies, and survival. In 21 cases a review of bone marrow smears had to be made, with the aim of classifying MDS and ANLL according to FAB criteria [4-6]. For the other cases, classification had already been done in accordance with the FAB criteria. Chromosome analysis at the time of diagnosis of the secondary blood disorder was done on bone marrow (BM) and/or peripheral blood (PB) from 2 4 - 4 8 - h o u r u n s t i m u l a t e d and control stimulated cultures with methotrexate synchronization. Karyotypes were obtained after R banding with acridine orange. As a rule, at least 25 m e t a p h a s e s were analyzed, of w h i c h ten were fully karyotyped. Chromosome abnormalities are described according to the ISCN [7]. The criteria a d o p t e d at the First International Workshop on Chromosomes in Leukemia were used for identification of abnormal clones [8]. Single abnormal cells were not taken into consideration. Cytogenetic results were correlated with treatment, time elapsed since diagnosis of the p r i m a r y disease, and survival. Survival was also analyzed in relation to age, sex, type of disease, and treatment. Statistical analyses were made using a log-rank test.

RESULTS

Clinical Characteristics The clinical characteristics of 76 patients are listed in Table 1. There were 40 men and 36 w o m e n with age ranging from 18 to 89 years at the time of diagnosis of the s e c o n d a r y disease (median age 57.5 years, mean age 55.5 years). The mean age was lower in patients w i t h previous Hodgkin's disease (40.3 years). The cases were distributed as follows: 19 Hodgkin's disease, five non-Hodgkin's l y m p h o m a , 12 m u l t i p l e m y e l o m a , two W a l d e n s t r 6 m ' s macroglobulinemia, 16 p o l y c y t h e m i a vera, one essential t h r o m b o c y t h e m i a , ten breast cancer, three other solid tumors, three m u l t i p l e sclerosis, one a u t o i m m u n e thyroiditis, and four exposed workers. Seventytwo cases had a d o c u m e n t e d history of c h e m o t h e r a p y and/or radiotherapy: 29 patients received only chemotherapy, ten only radiotherapy, and the rest had r a d i o t h e r a p y (RT) and chemotherapy. The mean time elapsing between first disease and the date of diagnosis of secondary bone marrow neoplasia in the patients with d o c u m e n t e d previous t h e r a p y was 7.1 years (range 1-21 years); m e d i a n time was 6 years. The m e a n time was longer in patients with a previous myeloproliferative d i s o r d e r (11.4 years). In the patients who received only radiotherapy, the mean

Therapy-related Leukemia and MDS

229

elapsing time was 9.3 years; in patients who received only c h e m o t h e r a p y it was 7.3 years, and in patients who received both it was 6.3 years. W i t h regard to the last four patients, one had received thorotrast 29 years before. Three cases were workers e x p o s e d to aromatic: hydrocarbons. The s e c o n d a r y bone marrow disorder was a m y e l o d y s p l a s t i c s y n d r o m e in 29 cases and acute n o n l y m p h o c y t i c leukemia in 47 cases. Twenty-seven of these leukemias (57.4%) were p r e c e d e d by a p r e l e u k e m i c stage, the m e d i a n duration of which was 5.7 months (range 1 - 2 3 months). Thirty-five patients were treated for their secondary disorder with standard protocols for m y e l o i d leukemia, cytosine arabinoside (ara-C), 6-mercaptopurine, and thioguanine; one {case 7) also received a bone marrow transplant (BMT). Three other cases received BMT as a first treatment (cases 12, 69, and 75), and the rest received only s u p p o r t i v e care. Median survival was short {7 months) and i n d e p e n d e n t of age, sex, type of p r i m a r y disease, elapsing time, and treatment.

Cytomorphologic Findings In all cases, an attempt was m a d e to assign classification according to the FAB criteria. Patients classified as having s-MDS had less than 30% blasts in the marrow, while diagnosis of s-ANLL was made when the percentage of blasts was greater than 30% in bone marrow. The range of blasts in the patients with s-MDS was 5 20%, while in s-ANLL the percentage ranged from 31% to 80%. Among 47 ANLL patients, type M2 was most c o m m o n (15 cases), followed by M4 (nine cases), M6 (four cases), M1 (two cases), M5 (one case), and M7 (one case). No cases of M3 were observed. The r e m a i n i n g 15 cases were unclassifiable according to FAB criteria. Among 21 cases that could be analyzed, seven presented increased cellularity, six normocellularity, and eight hypocellularity. M y e l o d y s p l a s t i c aspects including megaloblastic red series, hypogranulation, and pseudo-Pelgeration of granulocytic ce;!s, and small sized and megaloblastic megakaryocytes were found in most cases of s-ANLL. No Auer rods were observed.

Cytogenetic Investigations Karyotypes were successfully obtained in all cases (Table 2). Chromosome abnormalities were present in 58 patients (76.3%). The distribution of numerical and structural aberrations is reported in Figure 1. Involvement of chromosomes 5 a n d / o r 7 was present in 42 out of 58 cases (72.4%) with abnormal karyotypes. M o n o s o m y of c h r o m o s o m e s 7 as the only change (seven cases) or with other abnormalities (13 cases) was the most frequent finding (34.4% of abnormal cases). The second most c o m m o n l y affected c h r o m o s o m e was 5: ten patients had m o n o s o m y (17.2% of abnormal cases) and 16 had structural rearrangements (27.5% of abnormal cases). Chromosomes 3 and 12 were consistently involved in structural aberrations. Trisomy 8 was present in seven out of 76 cases. Chromosome 17 was rarely involved, in contrast to what has been suggested by other investigations [2, 22]. Furthermore, other abnormalities, such as t(8;21), t(15;17), and inv(16) typically associated with subgroups of de novo leukemia, were not observed in our series. In the total series, 19 out of 76 s h o w e d a normal karyotype {NN), only abnormal mitosis (AA) were observed in 45 cases, and a mixture of abnormal and normal mitoses were observed in 12 cases (AN). Cases with only a normal karyotype showed the highest survival from diagnosis (10 months), w h i l e the group with m o n o s o m y 7 and the group with c o m p l e x aberrations s h o w e d a survival of 7 months and 5 months, respectively (p < 0.0257) (Fig. 2).

Age/sex

46/M

23/F

28/F

52/M

55/M

34/M

23/F

24/M

54/F

47/M

64/F

24/F

48/M

32/M

27/M

26/F

54/M 58/F

1

2

3

4

5

6

7

8

9

10

11"

12

13

14

15

16

17" 18

Hodgkin's disease III B M.C. Hodgkin's disease IV B M.C. Hodgkin's disease III B N.S. Hodgkin's disease IV? M.C. Hodgkin's disease IV? L.P. Hodgkin's disease IV? L.P. Hodgkin's disease II A N.S. Hodgkin's disease I I I A N.S. Hodgkin's disease II B N.S. Hodgkin's disease III B M.C. Hodgkin's disease IV B N.S. Hodgkin's disease II A N.S. Hodgkin's disease IV? ? Hodgkin's disease I I I A L.P. Hodgkin's disease II! B L.P. Hodgkin's disease IV B N.S. Hodgkin's disease Hodgkin's disease

Primary t u m o r histology stage

Treatment for primary tumor

MOPP + RT CTX + VLB + RT

12MOPP + RT (4500 cGy)

18MOPP + RT (16000 cGy)

4MOPP + 4ABVD + RT

B + VCR + P + CTX + RT

7MOPP + RT (9000 cGy)

8MOPP + RT (4500 cGy)

6MOPP + RT (4000 cGy)

6MOPP + RT (4000 cGy)

12MOPP + 6ABVD + RT

6MOPP + VLB + ABVD + RT /3500 cGy] RT (4000 cGy)

VLB + P

VCR + VLB + M

12MOPP + BCNU + VLB + RT (3800 cGy) 6MOPP + RT (6600 cGy)

6MOPP + BCNU + VLB + RT

Clinical and hemetological findings

Patient

Table 1

7 10

5

8

4

8

3

3

7

6

5

2

8

11

7

5

4

10

Interval (yr)

Yes (8) --

Yes (5)

Yes (9]

Yes

--

Yes

Yes (4)

--

--

--

--

Yes

Yes (7)

Yes (9)

--

Yes

Yes (4)

s-MDS (too)

--

Yes (M4) Yes

Yes (M2)

Yes (M2]

--

Yes (M2)

--

Yes (M6)

Yes (M2)

Yes (M7)

Yes (M2)

Yes (M5)

Yes (M6)

Yes

Yes

Yes

s-ANLL

--

--

--

AraC + VCR + DNR

AraC

BMT

AraC

DN + AraC

Ara C

AraC + TG

AraC + DNR BMT

--

6-MP + HU

6-MP + HU

TG + AraC

--

HU + ARAC

Antileukemic treatment

9 mo (d) 0 mo (d)

7 mo (d)

11 mo (d)

10 mo (a}

1 mo (a)

16 mo (d)

5 mo (d)

8 mo (d)

2 mo (d)

1 mo (d)

40 mo (a)

0 mo (d)

9 mo (d)

14 mo (d)

7 mo (d)

2 mo (a)

16 mo (d)

Survival (mo)

O

b~

48/M

51/M

51/F

66/F

77/M

67/M

56/F

89/F

40/F

72/M 72/M

67/M

50/M 54/F

64/M

62/M

60/F

53/F

62/M 60/M 69/F 68/F

19

2O

21

22

23

24

25

26

27

28 29

30*

31 32

33

34

35

36

37 38 39 40*

Hodgkin's disease II A N.S. Non-Hodgkin's lymphoma Non-Hodgkin's l y m p h o m a PDLL Non-Hodgkin's l y m p h o m a PDLL Non-Hodgkin's l y m p h o m a PDLL Non-Hodgkin's l y m p h o m a CBCC Multiple myeloma lg A Multiple myeloma Ig A Multiple myeloma Ig GK Multiple myeloma Multiple myeloma Ig A Multiple myeloma Ig A Multiple myeloma Multiple myeloma Ig G Multiple myeloma Ig GK Multiple myeloma Ig GK Multiple myeloma Ig GK Multiple myeloma Ig G Waldenstr6m Waldenstr6m P o l y c y t h e m i a vera P o l y c y t h e m i a vera PR

CLB CLB + MELPH 32p 10 mCi 32p 26 mCi

PR + MELPH + CTX

VBAP + VCMP

MELPH

PR + MELPH + VCAP

VCR + CTX + ADR + RT PR + MELPH

PR + MELPH

CT CT

PR + MELPH + CTX

PR + MELPH

PR + MELPH

CLB + C V P +

CTX + CLB + VLB

CTX + PR

BACOP + CLB + CCNU + RT

CTX + ADR + VCR

6 M O P P + RT (7500 cGy)

4 4 5 11

8

5

7

3

3 4

2

6 11

5

4

1

2

10

2

7

5

7

Yes Yes Yes Yes

Yes (2)

Yes

Yes

Yes

Yes

Yes

Yes (8)

Yes (9)

Yes

Yes (3)

Yes (5)

Yes

Yes

Y e s

Yes (M2)

Yes (M6)

Yes Yes (M2)

Yes (M2)

Yes (M1)

Yes (M2)

Yes (M4}

Yes

m

AraC + VCR + PR + ADR

AraC + PR

AraC

AraC

AraC

Interferon

m

7 1 29 3

mo mo mo mo

(d) (a) (a) (d)

3 m o (d)

3 m o (a)

2 m o (d)

5 m o (d)

2 m o (d) 5 m o (d)

2 m o (d)

(d) 3 m o (d) 10 mo

10 m o (a)

11 m o (a)

7 m o (d)

1 m o (d)

10 m o (d)

0 m o (d)

10 m o (dl

4 m o (d)

1 m o (a)

t,o

50/M 55/M

84/F 65/F 42/F 45/F 80/F 51/F

58/F

56 57 58 59 60 61

62

57/F

62/F 72/F 60/M

76/F

61/F 62/M 78/M 52/I"

79/F

70/M 74/M 63/M

41" 42* 43* 44* 45* 46 47* 48* 49* 50* 51" 52* 53* 54 55

Breast cancer

P o l ' , c v t h e m i a w~ra Polvcvthemia vera Polvcvthemm vera Polw:vthemia vera Polvc themia vera Polvc themla vera Pol' ,cythemia vera Polycythemia vera Polycythemia vera Essential thrombocythemia Breast cancer Breast cancer Breast cancer Breast cancer Breast cancer Breast cancer

vera vera vera vera vera

Primary tumor histology stage

Polyc :themia Polvc themia Polyc 7themia Polw:vthemia Pol',cvthemia

Continued

Age/sex

1

Patient

Table

7 2 2 5 4 3

M a s t e c t o m y -~ RT M a s t e c t o m y + M E L P H + RT M a s t e c t o m y + CT + R T M a s t e c t o m y + M E L P H + RT Mastectomy + RT Mastectomy + CMF + RT (4000 cGy) Mastectomy + CMF + RT ( 1 2 9 0 0 c G v /

4

14 21 7 6 4 17 10 10 13 20 5 15 11 10 16

Interval (yrl

3 2 p 28 m C i ~- B U S BUS 3 2 p 22 m C i + H t T 32p 4 mCi + BUS 3 2 p 5 m C i -~ B U S CLB + BUS HU + BUS 3 2 P 15 m C i CLB + BUS 3 2 p 21 m C i + B U S 32p 6 mCi + BUS 32p 8 mCi 32p 4 mCi + MELPH + BUS BUS 3 2 p 2O m C i

Treatment for primary tumor

(4) (7) (3) (8l

--

Yes

Yes -Y e s (24) Y e s (2}

Yes Yes Yes Y e s [2) Y e s (9)

--

Yes Yes Yes Yes

Y e s (7)

s-MDS {mol

-

(M4) (M2)

(M4)

{M4) {M2]

Y e s (M2)

-Y e s (M4) Yes Yes Yes --

Yes (MI) Yes (M4}

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

s-ANLL

AraC

PR

AraC AraC VCR + ADR

-AraC + TG + DNR

AraC

---

AraC - DNR --

-H U -- 6 - M P HIJ

Antilenkemic treatment

mo mo mo mo mo mo

mo mo mo mo mo mo mo mo mo mo mo mo mo mo mo

(a) (d) (a) {d) (d) (d)

(d) (d) (d) (d} {d) (d) (d) (d) (d) (d) (d) (d) (d} {d) (d]

8 m o (d)

5 2 26 8 5 16

8 8 4 7 14 9 2 6 1 1 34 7 5 8 10

Survival (mo)

t-O ¢.o t',o

6 0/ F 61/M 51/M

5 5/ M

40/M 50/M 74/F 63/M

67/M 78/M

18/ M 26/M

65 66 67

68

69* 70 71" 72*

73 74*

75 76*

Benzene exposure Benzene exposure

Testicular chorionepithelioma Multiple sclerosis Multiple sclerosis Multiple sclerosis Autoimmune thyroiditis Thorostrat Leather i n d u s t r y worker

Breast c a n c e r L un g c a n c e r Testicular seminonla

Breast c a n c e r Breast c a n c e r

Dose is u n k n o w n

CTX CT CTX CTX + AZT

RT

M a s t e c t o m y + MELPH M a s t e c t o m y + MELPH + 5-EU + RT (3000 cGy) M a s t e c t o m y + MELPH + RT CT + BMT RT (6000 cGy)

--

29

6 3 13 13

12

3 4 11

7 8

Yes (2J Yes (1)

Yes (4) Yes

Yes Yes (2) Yes Yes

Yes (6)

Yes (2) Yes Yes

Yes --

---

Yes (M2) Yes (M4)

Yes {M61

--

-Yes (M4}

Yes (M2)

Yes

-Yes (M2J

BMT TG + AraC

HU Ara C

AraC

BMT A raC + DNR

AraC + DNR

AraC

--

--

-AraC + ADR

(a)

mo mo mo mo

(d) {d) (d) (d)

57 m o (a) 0 mo (d)

8 m o (d} 2 mo[d)

3 3 3 7

7 mo (d)

2 mo (a/

4 mo

2 mo (d)

2 mo (d) 5 m o (d)

* Included in previous publications.

Abbreviations: M. male; F, female; d, died: a. alive: M.C.. mixed celhdarity: N.S., nodular sclerosis: L.D., lymphocytic depletion: L.P., lymphocytic predominance; PDLL, poorly differentiated lymphocytic lymphoma; CBCC, centroblastic centrocytic: MOPP. mechloretamine, vincristine, procarbazilm, and prednisone: BCNU, carmustine: VLB, vinblastine; CVR, viln:ristine; ABVD, doxorubicin, bleomycin, vinblastilm, aml dacarbazine: MELPH, melphalan; P, procarbazine: CTX, cvclophosphamide ADR, adriamycin; BACOP, vincristine, cyclophosphamide, adriamycin, bleomycin, prednisone: CLB, chlorambucil; CCNU, Iomustine: PR, prednisone: CVP. cyclophosphamide, vincristine, prednisone: \'CAP, vincristine, cyclophosphamide, adriamycin, prednisone; VBAP: vincristine, BCNIL adriamycin, prednisone: VCMP, vincristine, cyclophosphamide, melphalan, prednisone: HI J, hydroxyurea: B[IS, Imsulphan: CMF. cyc:h~phosphamide, methotrexate, 5-ttuoronracil: 5IFIJ, 5It]m)rotlracil; AZT, azathioprine; M, nitrogen mustard: Ara C, Cytosine arabinoside: TG. thioguanine; 6-MP. 6-mercaptopurine; DNR, daunorubicin: I)N, daunomycin: B. [31eomycin: AMSA, amsacrine,.

5 9/ F 4 4/ F

63* 64

bO ¢...O ¢.*3

234 Table 2

Cytogenetic

Patient

Date

Sample

1 2 3

5/81 10/80 5/77

4

8/81 11/81

5

analysis C u l t u r e (hr)

Karyotype

Percent ~

BM BM BM

48 48 48

100 100 40 60

BM BM

48 48

45,XY,-7 46,XX 47,XX, 3 , - 1 7 , + m a r l , + m a r 2 , + m a r 3 46,XX,-3,-17,-11, + m a r l , + mar2, + m a r 4 45,XX,-7 45-50,XY, + Y , - 5 , - 7 , - 18,t(19;?) (q?;?),t(19;?)(q?;?),mar1,+ 5 m a r 45-50,XY, + Y , - 5,del(7)(q21q33), t(19;?)(q?;?),t(19;?)(q?;?), + 5 m a r 45-50,XY,+ Y , - 5,del(7)(q21q33), t(12;?)(p?;?),t(19;?)(q?;?), t(19;?)(q?;?), + m a r l 46,XY 47-48,Y,(-X),-8, + m a r l , + m a r 2 , + mar3 46,XX 4 5 , X Y , - 5 , - 21,der(4),+ m a r l 46,XY,-5, 21,der(4),+mar1+mar2 4 6 , X Y , - 5 , - 8 , - 1 9 , - 21 ,der(4), + mar3, + mar4, + m a r 6 4 6 , X Y , - 5 , - 8 , - 1 9 , - 21,der(4), + m a r 3 , + m a r 4 , + mar5 6 9 , X X , + X , + 1,+ 2,+ 3 , + 4 , + 8 , + 8, +10,+10,+11,+13,+14,+14, +15,+17,+ 18,+19,+20,+20, +21,+22,+22,+mar 7 3 , X X , + X , + 1,+ 2,+ 3 , + 4 , + 6 , + 6, +7,+8,+10,+11,+11,+13,+13, +14,+15,+15,+17,+18,+18, + 19,+20,+ 20,+21,+22,+22, + mar 46,XY,del(7)(p12p21) 46,XX,t(1;3)(p36;q21} 46,XX 45,XY, 7 46,XY 46,XX 46,XX 4 5 , X Y , - 16,t(3;9)(p21;q21), inv(5)(q14q35),t(6;16)(p22;q21) 46,XX,t(3;8)(q26;q23),t(9p15q),+ f 46,XX,t(1;?)(q?;?),t(3;8)(q26;q23), t(9p15q),+f 44,XY,-5,-7,- 12,-18, t(1;10)(p21;p12),del(16)(p?), + marl, + mar2 4 3 - 4 6 , X Y , - 2 , ( - 3),+ der(19), [+der(19)],(- 12),(- 13),-13, + mar 46,XX 45,XX,- 7 46,XY 46,XY 45,XY,-7 45,XX, 7 46,XX,-7,+mar1

6

4/82

PB

72 + P H A

7 8

3/85 3/82

BM BM

48 48

9

10 11" 12 13 14 15 16 17"

2/83

PB

48

1/85 6/84 12/81 2/79 4/86 11/82 8/79 85

BM BM BM BM BM BM BM BM

48 48 48 48 48 48 48 48

18

8/81

BM PB

48 48

19

5/87

BM

48

20

9/78

BM

48

21 22 23 24

3/85 11/83 1/81 10/84

BM PB BM BM

24 48 48 24

25

4/77

BM

48

100 50 29 21

46 54 100 30 20 30 20 50

50

100 100 100 100 100 100 100 100 40 40 87

100

100 100 73 8O 18 60 40

235 Table 2

Continued

Patient

Date

26 27

Sample

Culture (hr)

Karyotype

Percent b

46,XX 46,XX 46,XX,i(7q/ 46,XX 46,XX,del(1)(q?),i(7q) 46,XY,del(2)(q24),t(3q-;3q +) 46,XY,t(3q-;3q +) 46,XY 45,XY,del(3)(p14),- 5,+ f 4 3 , X Y , 2 p + , - 3 , - 7,-20, t(1;11)(q12;q14),der(4), inv(5)(q12q32),Sq+,del(11)(q14), 12p+ 46,XY 45,XY,- 5 , - 19,- 20,+marl,+mar2 46,XX 46,XX,inv(2)(q22q32),- 7,i(9p/,- 17, -18,+3mar 46,XY,der(3),del(7)(pllp21) 46,XY,del(2)(p14),del(7)(pllp21) 46,XY,-7,+21 45,XY,- 7 46,XX 5 3 , X , - X , - 8 , + 9 , + 11,+ 15, + del(18)(q22),+ 19,+ 21,+ 21, +2mar 46,XX 47,XX, + mar 47,XY,+8 45,XY,- 7,del(21)(q21) 46,XX 46,XX,del(11)(q14),del(12)(q?), 18p+ 46,XX,del(11)(q14),del(12)(q?), 18p+ 47,XX,t(1;9)(q11;qll),del(11) (q14),del(12)(q?),18p + ,+mar 43,XY,- 5 , - 7 , - 1 1 , - 1 7 , + m a r l 47,XY,+8 46,XY,del(5)(q14q32), del(13)(q13q31) 46,XX,del(7)(p14) 47,XX,+9 46,XY 46,XY 48,XX,+8,+mar1 50,XX,÷ 1,del(5)(q12q32), +8,+10,÷11 44,XX,del(5)(q12q23), - 12,- 1 3 , - 1 7 , + m a r l 46,XX 46,XX,del(13)(q13q21) 46,XX 46,XX,del(5)(q23q32), inv(12)(p12q23) 46,XX 46,XX,del(13)(q13q21)

100 2o 8o 2o 8O 4o 6O 22 55 10o

3/86 9/82

BM PB

48 48

6/83

BM

48

28

5/84

PB

24

29

10/86

BM

24

30*

5/86

BM

24

31

4/79

BM/PB

48

32

12/85

BM

48

33

11/83

BM

48

34

1/80

BM

48

35

6/86

BM

24

36

10/80

BM/PB

48

5/82 9/79

BM BM BM BM

48 24 72 48

3/81

PB

48

37 38 39 40*

5/82

4/79

41" 42* 43*

6/77 8/84 4/79

BM BM/PB BM/PB

72 48 48

44* 45* 46 47* 48 49*

6/85 2/74 3/78 3/85 5/83 9/82

BM/PB BM/PB BM BM/PB PB BM

48 48 48 24 48 48

50*

3/85

BM

48

51"

8/83

BM

48

10/84

BM

48

7/85

BM

48

5O 50 76 22 4O 4O 36 64 8O 2O

66 13 100 100 100 lO0 73 26 84 100 lO0 100 100 93 100 10o 100 100 30 70 45 45 83 16

236 Table 2

Continued

Patient

Date

52*

4;80

PB

48

53*

277

BM

48

54 55 56 57 58 59 60 61 62 63

4/82 12,'79 7/81 4,'84 4/83 10/81 10/86 6/83 4,'84 10/82

PB BM BM BM/PB PB BM BM BM BM PB

48 48 48 48 48 72 48 48 48 48

64

4:85

BM

48

65

12781

PB

48

66

!)/85

BM

48

67

4/87

BM

24

68

386

PB

48

69

1086

BM

48

70

2,'79

BM

48

71"

1/86

BM

24

72

11:85

BM

48

73

2/78

PB

48

Sample

C u l t u r e (hr)

K a ryot ype 47,XY,del(5)(q14q32),+ 9. del(11}(q21),del(13)(ql 3q31 ) 46,XX,t(6;22)(q27;qll), 2 1 , + m a r l 46.XX,t(3q ;3q +),t(6;22)(q27;q11), 7. -. 21,÷ m a r l , + mar 45,XY. 7 46,XY,-6, 20,+2mar 46,XX 46.XX

45,XX,del(3q),

t(12:?}{q24:7), 74*

4/8(5

BM

24

75

4/82

PB/BM

48

76*

4/76

BM/PB

48

7

46,XX 46,XX 46,XX 46,XX 46,XX,del(5)(q14q32),t(6:?)(p22;?), del(20)(q11) 46.XX 47,XX,+8 45.XX,t(3;15][q11:q11). del(5)(q14q32].del(7)(q31), 21 .+f 46,XY,-- 5.5q + ,del(10](q23q25], dH(13)(q12q21),~mar 46.XY 44,XY.del(4)(q22q 34), del(5)(q12q32}, 12, t(12:21)(q11;q22), 17,---22, + marl 44,XY,del(5}[q23q32). 16, t[7:15:16)(q11:q11:q11),- 18, l[12:18)(p12;ql 1) 46,XY.t(3;6){p11:p24},d{~,r(4}, 7,9p +.dr!r( 19}, e l na r 45,XY 46,XY. 7 , + l n a r l 45,XY, 7, 9 , + m a r l 46,XX, 3 , - 5,+ der(5).t(5;?)(q13;?], der(6p), - 19, + der(19), t{ll:19)(q13;p13} 44.XY, 3, 5, 1 2 , + t i e r ( 1 2 ) . - 1 5 , de, l ( 1 7 ] ( p 1 2 } , + m a r l 46,X, Y,t(1;4)(p31;p13), 3 , - 5 , 7, der{9q),del(12)(p12),

* Included in previous publications,

100 50 50 100 100 100 100 IO0 93 100 100 93 100 50 50 88

70 3O 80

100

100 30 40 30 100

100 100

10, 17,-18,

+ 6ma r 46,XY 46,X. Y, 7 , + 8 . - 1 3 , 'del(5)(q14q34),del(6)(p22), inv(121(p12q23),del(l 7)(p11), 2ma r 46,XY 46,XY,del(3)(q14q22} 46,XY,t(3;16)"(q11;p11), t{9:10)(?p24:p 12),t(4;5)(p13:q14)

" Family translocation. ~'Does not include ~ells with randmn abnormalities.

Percent ~

50 50

60 40 100

237

+

~1 2

34

.•11

Figure 1 s-ANLL.

12' 13 14 15 Ill 17 111 19 20 ~'1 22 x y

1 2

4

6 7 1

I0 II 1 l l 3 14 15 15 1 / l l

It ZO ZI 17 x

Yl

Numerical (left) and structural (right) aberrations in 58 patients with s-MDS and

F i g u r e 2 Survival in patients with normal karyotype (A/, monosomy 7 as sole anomaly (B), and complex karyotype (C). I J)'--A

0,8

A~__a. 8--,E-C I

Q8

0,4 0,2

C--C C-C C

?

13 0- . . . . . . .

5 .......

-1~) . . . . . . .

fS- . . . . . .

C }0 .......

2'6- . . . . . .

30 ......

-~5- . . . . . .

-40 ( m o n t h s )

238

A. Iurlo et al.

o ÷

÷

o

o

÷

+

0

0

0

x

x

x

÷

x

x

÷

÷

x

x

Figure 3 Chromosomes involved m recurring rearrangements in s-MDS-ANLL. Data from the literature (reference between brackets), x :[20]; ©:[1]; + :[3]; ~:[2]; :[21]; •:[22]; * :[11].

DISCUSSION Our 76 cases with s-ANLL and s-MDS belong to a group that was very heterogeneous with regard to the p r i m a r y condition. Nevertheless, we can confirm all important clinical and hematologic findings reported in other big series such as sex and age distribution and time of appearance [1-2, 9-12]. A large number of cases reported in this p a p e r represent patients treated for m u l t i p l e myeloma, where the risk of d e v e l o p i n g an acute leukemia was calculated to be 14% w h e n m e l p h a l a n was a d m i n i s t e r e d for more than 2 years [13] or with total critical dose of m e l p h a l a n of about 700 mg [14]. In agreement with previous reports, the most c o m m o n cytogenetic a n o m a l y found in this large series of patients was m o n o s o m y 7 [15]. In the present series we also i n c l u d e d four patients without history of c h e m o t h e r a p y a n d / o r r a d i o t h e r a p y but who d e v e l o p e d a secondary blood disorder after toxic exposure. One of these patients (case 73) is particularly interesting because only a few cases of s e c o n d a r y l e u k e m i a after thorotrast have been reported in the literature. This radiographic contrast m e d i u m seems to p r o d u c e an injury to m u l t i p o t e n t stem cells, leading to the a p p e a r a n c e of marker chromosomes after a long time interval (ranging from 16 to 45 years) [16]. Our case d e v e l o p e d a m y e l o d y s p l a s t i c s y n d r o m e after 29 years, followed by an acute l e u k e m i a classified as M6. Similarly, most Japanese cases who d e v e l o p e d s-ANLL after administration of thorotrast were diagnosed as having an acute e r y t h r o l e u k e m i a [17]. With regard to morphologic aspects, the erythroid series a p p e a r e d normal in only two cases, w h i l e megakaryocytes were dysplastic in all cases but one. The most frequent m y e l o d y s p l a s t i c features, involving one or all series, were represented by megaloblastosis in the red cell series; degranulation, hypersegmentation, and pseudo-Pelger a n o m a l y in the granulocytic series; and micromegakaryocytes and megaloblastosis in the megakaryocytic series. All these observations are in good agreement with the definition of secondary hematologic tumor as a trilineage bone marrow d i s o r d e r [18, 19]. A l t h o u g h c l i n i c a l l y no n e w elements emerged from our study, attention should be d r a w n to some of the c h r o m o s o m a l results. Cytogenetic investigations s h o w e d a high p r o p o r t i o n of c h r o m o s o m e abnormalities, 58 out of 76 cases (76.3%). This percentage was higher in patients with an antecedent history of multiple m y e l o m a or macroglobu l i n e m i a (92%) and myeloproliferative disorder (82%) than in the patients with previous breast cancer (40%). Interestingly, a l l secondary hematologic disorders a p p e a r i n g after three other solid tumors as primary neoplasia showed an abnormal karyotype. Looking at a large series of c h r o m o s o m e studies p u b l i s h e d in the literature [1-3,

Therapy-related Leukemia and MDS

239

11, 20-22], c h r o m o s o m e s 1, 3, 4, 5, 7, 8, 12, 14, 16, 17, 18, 21, and 22, especially n o n r a n d o m l y s h o w e d structural and numerical anomalies (Fig. 3). A n overview of all structural and n u m e r i c a l changes in our cases is given in Figure 1. Loss of c h r o m o s o m e 7 was the most c o m m o n finding (34.4% of abnormal cases), while this c h r o m o s o m e had structural rearrangement in only 11.9% of the cases. Interestingly, the hypothesis of a correlation between m o n o s o m y 7 and 5 with a previous c h e m o t h e r a p y [23] seems to be confirmed, as we did not observe loss of c h r o m o s o m e 7 in cases who received only radiotherapy. Chromosome 5 was more frequently involved in structural (27.5%) than in numerical aberrations (17.2%). A p r e v i o u s l y p r o p o s e d association between 5 q - and radiotherapy as the only treatment [23] could not be found in our study. Patients with 5 q - represented a heterogeneous group (chemotherapy, two cases; RT, three cases; c h e m o t h e r a p y and RT, four cases). Concerning possible correlations between karyotype and antecedent disease, m o n o s o m y 5 was more frequently present in nonhematologic diseases, while m o n o s o m y 7 was observed in all types of malignancies, although less frequently in patients with previous breast cancer or p o l y c y t h e m i a vera. Finally the occurrence of a 5 q - a n o m a l y was i n d e p e n d e n t of the nature of the preceding neoplasia, i.e., hematologic disorders or solid tumors. The third c h r o m o s o m e most frequently involved in numerical and structural aberrations was c h r o m o s o m e 3, observed in 18 out of 58 abnormal cases. The abnormalities i n c l u d e d structural rearrangements of the long arm in eight cases, of the short arm in three cases, and m o n o s o m y in six cases. The involvement of c h r o m o s o m e 3 may be observed in de novo ANLL [24] as well as in secondary MDSoANLL [20, 21]. Structural abnormalities of c h r o m o s o m e 3 involving breakpoints near bands q21 have been reported in de novo ANLL associated with high platelet counts and m o r p h o l o g i c a l l y abnormal megakaryocytes in bone marrow. These hematologic findings were not present in our two cases, as well as in a series of s e c o n d a r y l e u k e m i a reported by Whang-Peng [20]. Interestingly, one of our two patients s h o w e d a t(3;8)(q26;q23). Similar breakpoints were recently observed by Mertens et el. [25] in a t(3;8)(q26;q24) in one patient with MDS and occupational exposure. C h r o m o s o m e 12 showing a deletion involving the short arm was found in seven cases (12% of abnormal cases) in our series. Several studies have been previously p u b l i s h e d on the association of a 1 2 p - rearrangement with secondary MDSoANLL [26-28]. A b n o r m a l c h r o m o s o m e 17 was present only in eight cases, none of them with a history of previous toxic exposure, as observed by Benitez et el. [1]. C h r o m o s o m e 21 was involved in numerical aberrations; three cases s h o w e d a loss and three a gain. We observed only two cases with a structural rearrangement on 21q, as reported by Pedersen-Bjergaard [22]. In our series seven out of 58 abnormal cases s h o w e d a gain of c h r o m o s o m e 8. This aberration is one of the most c o m m o n n u m e r i c a l changes in de novo hematologic tumors, of both l y m p h o i d and m y e l o i d type [29]. All these data clearly show that in a d d i t i o n to total or partial losses of chromosomes 5 and 7, w h i c h appear to be highly specific, the frequency and type of the other n o n r a n d o m c h r o m o s o m e changes are also important. Although a certain variability with regard to the c h r o m o s o m e s involved and the nature of the c h r o m o s o m e changes is observed, c h r o m o s o m e s 3, 8, 9, 12, 17, and 21 are obviously more involved than others, as illustrated in Figures 2 and 3. These observations should be considered if one wants to u n d e r s t a n d the pathogenetic m e c h a n i s m s of secondary leukemias and MDS.

240

A. Iurlo et al.

This work was supported by the Inter-University Network for Fundamental Research sponsored by the Belgian government (1987-1991). A. I. is a fellow of the Associazione Italiana per la Ricerca sul Cancro.

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